Locating the Femoral Vein: Practical Techniques

1. NAVEL Mnemonic (Know Your Anatomy)

Nerve - Artery - Vein - Empty space - Lymphatics

2. Standard Surface Anatomy (Artery First) Technique

• Position the patient supine, in slight reverse Trendelenburg (dilates the vein), hip slightly abducted, leg slightly externally rotated.
• Palpate the femoral artery pulse at the midinguinal point (midway between the anterior superior iliac spine and the pubic symphysis).
• The femoral vein lies 1 finger-breadth (0.5-1 cm) medial to the artery, about 1-2 cm below the inguinal ligament.
• Needle entry is at a 45-degree angle.

3. The "V-Technique" (Especially Useful in Pulseless/Hypotensive Patients)

• Place your thumb on the pubic tubercle and your index finger on the anterior superior iliac spine (ASIS).
• The femoral vein lies at the webspace between your thumb and index finger (the "V"), just inferior to the inguinal ligament.
• This uses bony landmarks - not the pulse - so it works even during CPR.

4. Ultrasound Guidance (Most Reliable)

• Use a linear or curvilinear probe just below the inguinal ligament.
• The femoral vein is compressible on probe pressure (the artery is not) - this is the key differentiating feature.
• The vein is non-pulsatile and has thin walls.
• Augmentation (squeeze the calf) will increase flow in the vein on Doppler.

5. Important Pearls

Foley Catheter Insertion: Step-by-Step Procedure

Indications

• Acute urinary retention
• Urine output monitoring in critically ill/injured patients
• Urethral/prostatic obstruction compromising renal function
• Collection of sterile urine specimen
• Neurogenic bladder (intermittent catheterization)

Contraindications

• Suspected urethral injury (blood at meatus, high-riding prostate, perineal hematoma, pelvic fracture) - urethrogram must precede catheterization
• Known or suspected urethral transaction

Equipment Needed

• Sterile catheterization tray containing:
  • Foley catheter (14-16 Fr for most adults; 14-18 Fr coudé for men with prostatic enlargement)
  • Sterile gloves
  • Sterile drapes/fenestrated drape
  • Antiseptic solution (povidone-iodine or chlorhexidine) + swabs/cotton balls
  • Water-soluble lubricant (or 2% lignocaine gel for males)
  • 10 mL syringe prefilled with sterile water (for balloon inflation)
  • Collection bag and drainage tubing
  • Specimen container (if needed)

Step-by-Step Procedure

PHASE 1: Preparation

• Confirm indication, check for contraindications
• Explain procedure to patient, obtain consent
• Ensure privacy

• Wash hands thoroughly before opening any equipment

• Female: Dorsal recumbent (supine, knees flexed, thighs abducted and externally rotated - "frog leg" position)
• Male: Supine, legs slightly apart

• Open tray using aseptic non-touch technique
• Don sterile gloves
• Arrange sterile field: antiseptic swabs, lubricant, catheter, syringe
• Test balloon integrity by inflating with 10 mL sterile water, then deflate completely
• Lubricate the catheter tip (5 cm for females; 15-20 cm for males, or use pre-filled lignocaine gel syringe)
• Connect catheter to drainage bag

PHASE 2: Cleaning & Draping

• Place sterile fenestrated drape over the perineum, exposing only the meatus

• Female: With non-dominant hand, separate the labia minora to expose the urethral meatus. Clean from anterior to posterior with antiseptic swabs - use each swab once only in the order: far labium, near labium, then directly over the meatus. The non-dominant hand is now contaminated - do not release the labia until the catheter is inserted.
• Male (uncircumcised): Retract foreskin fully before establishing sterile field. Wrap a gauze pad around the retracted foreskin at the coronal sulcus to prevent it from sliding forward. With non-dominant hand, hold the penis at 90° to the body (perpendicular/upright). Clean the meatus in a circular outward motion, 3 times, using a fresh swab each time.

Important: The hand used to hold the penis/labia is now considered contaminated. Only the dominant (sterile) hand handles the catheter.

PHASE 3: Catheter Insertion

• Pick up the catheter 5-7 cm from its tip, coiled loosely in the dominant hand
• Female: Insert catheter 5-7.5 cm (2-3 inches) or until urine flows
• Male: Hold penis at 90° (perpendicular to body to straighten the urethra). Insert catheter slowly 15-20 cm (to the hilt/bifurcation) before inflating the balloon. The urethra is ~20 cm long. Never inflate the balloon until urine is flowing and the catheter is fully advanced.

• Wait for urine to flow freely into the drainage bag - this confirms the catheter tip is in the bladder
• If no urine flows: check the bag is below bladder level; try gentle aspiration; consider that patient may be dehydrated

PHASE 4: Securing

• Inject 10 mL of sterile water (not saline, not air) via the balloon port
• Gently pull back on the catheter until resistance is felt - this seats the balloon against the bladder neck

• In males: secure to the inner thigh or lower abdomen to avoid penile-scrotal angle pressure
• In females: secure to the inner thigh
• Keep drainage bag below bladder level at all times to ensure gravity drainage - never on the floor

• Reduce the foreskin to its normal position immediately to prevent paraphimosis - this is a commonly forgotten step

• Remove drapes, dispose of sharps and waste
• Remove gloves, perform hand hygiene
• Document: catheter size, balloon volume, colour and amount of urine drained, any difficulty

Quick Reference Summary

Key Pitfalls to Avoid

Catheter-Associated UTI (CAUTI) Prevention

• Use smallest effective catheter size
• Remove catheter as soon as it is no longer needed
• Keep drainage bag below bladder level; never let it touch the floor
• Maintain a closed drainage system
• Routine antibiotic prophylaxis is not recommended for catheterized patients